I went to a bunch of talks on en bloc capsulectomy, as I do so many capsulectomies and explants in my practice. I wanted to see what is out there and how other doctors are advising. One of the presenters was focused on always doing 100% capsulectomy removals on all patients. He is operating on people who think they have Breast Implant Illness (called BII).
He first started with his terminology:
- En bloc is a specific term, originally started by oncologists. “To remove a tumor mass in its entirety in one continuous layer to avoid spillage, with normal tissue around it”. He emphasized it is whole, with one continuous layer, to avoid any spillage. He stated “En bloc is not guarantee-able or requestable.”
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- My thought? I agree with his definition, and with the fact you cannot guarantee en bloc.
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- Total Capsulectomy: This is removing the whole capsule, but sometimes there are small openings in it, which could allow “spillage.”
- He stated you need to remove the entire capsule in certain cases: ALCL cancer, ruptured implants, calcified implants. I agree with this.
- He then did a review of his patients. He specializes in explants, and had done hundreds. He analyzed his results:
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- 460 cases. Of those, he was able to do 1/3 as true en bloc.
- Age ranged 25-74 years. Median implant age: 12 years.
- 175 were saline, 228 silicone.
- Chance of en bloc removal was higher when the implants were ruptured- 82% vs 32%. He hypothesized, and I agree, that older ruptured implants tended to have thicker capsules and were placed in front of the muscle. as was the primary technique until the late 1990s. Both of these facts- thicker capsule, and in front of the muscle- make a total en bloc much easier. The average age of a ruptured implant was 17 years.
- He found the en block percentage for implants in front of the muscle was 76%. (again, most of these are older likely leaking implants)
- He did 72% of the explants through a breast lift incision, 28% through the inframammary incision.
- He was forceful about low activity after surgery, as he has had hematomas at 2-3 weeks out from surgery. He hypothesizes this is from the muscle trying to reattach to the tissue, and you “rip” the muscle. He lamented we cannot cast the breast like a broken arm. “I am a dictator when I talk to them about activity.”
- Breast Implant Illness. He said 88% of his patients complained of this, and that 80% were “better” after surgery.
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My thoughts?
When doing a capsulectomy I always try to remove it all. Period. But there are times where the risk of issues is not worth trying to get every last bit, and the other presenters stated this fact as well. In some patients with breast implants behind the muscle where the capsule is super thin, the capsule is adherent to the underlying ribcage. In these patients to try to get the capsule off the rib can cause bleeding, a pneumothorax (where the lung deflates), or pain. My thoughts, echoed by many of the other presenters, was in a whisper thin capsule there is no reason to have the risks of those big issues for what is not a pathologic capsule. Leaving behind a small patch of capsule, which I cauterize and soak in antibiotic solution, is okay. What did this surgeon do? He said in those patients he removes the periosteum of the rib to get the whole capsule out. This is what created the ruckus. When you remove periosteum, you can leave a patient with chronic pain. In super thin patients, where you can see the whole ribcage moving with their heartbeat, this seems like a crazy risk. If it made a difference in symptoms, recovery, something, maybe it would be worth it. But a pathologic bad capsule is NOT thin- it is thick, calcified, and yucky- which makes it easy to remove.
When he talked about Breast Implant Illness, his statistics caused a bruhaha with the other presenters. He stated 80% of his patients were better after surgery. But when questioned, his “better” was only assessed 30 days after surgery, and if anything was better- they feel “better,” less back pain, less anxiety, less neck pain, etc- it was put into the better category. The other presenters, rightfully, focused on what was he measuring? A general “I feel better” is not scientific, and tons of his patients were getting breast lifts and reductions. Breast reductions are AWESOME to help with posture, neck and back pain, so saying it helped with Breast Implant Illness isn’t correct. He needs to look at the symptoms specifically of BII and have a longer timeframe.
My thoughts? Thick capsules and hard breasts hurt. I think in those patients many of them feel better when you remove the hard implant. They can feel better because they now have a soft chest again, the breast feels like a breast should, and they can lie on their stomach and hug people. They may feel better because they are glad to have the foreign object out of their body. If they were droopy and had heavy breasts, removing the implant and doing a lift is a breast reduction- and if you want to see a happy patient, read all my blogs about the joys of breast reductions. Many of those with thickened capsules I think have biofilm- and biofilm is chronic inflammation.
So to summarize? I am a huge fan of removing implants, particularly if you are too big, ruptured, hard, or droopy. I don’t know if I agree with him about total capsulectomy 100% of the time. Taking off periosteum for a thin, benign capsule seems overkill, particularly when other scientific papers have shown there is no benefit for BII symptoms.